The inquest into the death of a mother-of-five, who begged medical staff not to let her die, has concluded that her death was avoidable and contributed to by neglect. The coroner also accepted that Article 2 of the European Convention of Human Rights, the right to life, was engaged because of the role of the state in her death.
Area Coroner Sonia Hayes concluded that Laura-Jane Seaman, 36, died because of basic failings to recognise a loss of consciousness as a maternal collapse. She concluded that there was an inability to obtain basic vital signs which were incorrectly attributed to faulty equipment rather than an obvious deterioration in her condition. There was a failure to escalate her care to more senior staff, which was mandated, and a Multi Disciplinary Team review would have resulted in care and treatment which would have saved Laura-Jane’s life.
The coroner accepted that failures had occurred by several members of staff at Broomfield Hospital, across a very large number of medical disciplines and seniorities, across both the clinical and midwifery teams, and even across the laboratory and IT teams.
The inquest concluded on 12 August 2024 at Essex Coroners Court, following a 16-day inquest hearing. Laura-Jane, of Witham in Essex, died at Broomfield Hospital, part of Mid and South Essex NHS Foundation Trust, on 23 December 2022.
At the start of the inquest a pen portrait of Laura-Jane was read to the court. Her family told the court how important her large family was to her and that she valued being a mother above all else. She was described as someone who “would give you the shirt off her back and the shoes off her feet”. Laura-Jane volunteered with the rough sleepers in the local area and during lockdown provided hot meals for local families who were struggling. She worked hard as a night staff support worker enabling people with learning disabilities to live safely in the community.
The inquest heard Laura-Jane attended Broomfield Hospital on 21 December 2022 after experiencing contractions at home. She was nine months pregnant. Laura-Jane’s labour progressed well and was relatively short.
After her birth she recovered well and was able to breastfeed her baby, was sat up in bed, and planned to go home following discharge of her baby. However, just under two hours later, Laura-Jane started to feel unwell and deteriorate.
The court heard that Laura-Jane’s deterioration in the hours after delivery was not recognised and was not escalated for more senior review. During her deterioration she asked clinicians “am I bleeding”, said “I feel like I am gushing” and begged “please don’t let me die”. However, despite being at high risk of post-partum haemorrhage, her concerns were not escalated. Medical staff caring for her put her symptoms down to dehydration and when she lost consciousness, she was simply given a biscuit. The clinical team labelled this loss of consciousness as a faint, however, expert evidence has confirmed that Laura-Jane had experienced a maternal collapse which warranted obstetric review.
Laura-Jane’s observations were recorded onto a cardiotocograph (CTG) print out rather than a Modified Early Obstetric Warning Score (MEOWS) chart, which meant that prompts for escalation on the MEOWS chart were not followed.
Evidence given at the inquest revealed that Laura-Jane’s clinical record was not accessible to medical staff in other departments in the hospital, which led to clinical decisions being made in isolation. This included clinicians not being handed over in full her observations, test results and clinical picture. Additionally, clinicians also failed to undertake their own assessments of Laura-Jane. Many clinicians did not have access to her notes before Laura-Jane went into cardiac arrest. They were therefore not aware of her medical history and observations, therefore made the unlikely diagnosis that she had a pulmonary embolism. Before conducting appropriate investigations to confirm this diagnosis, she was given an anticoagulant called Clexane, which worsened the bleeding.
At around 6.30am on 21 December 2022, Laura-Jane went into cardiac arrest as a result of major internal bleeding, finally identified following a bedside scan, resulting in her undergoing four surgeries, requiring multiple blood transfusions. There was a delay in the recognition and treatment of Laura-Jane’s internal bleeding (haemorrhage) and the massive haemorrhage protocol was not triggered.
The family are represented by Suzanne White, partner and head of the clinical negligence department, and solicitor Camilla Browne, both of law firm Leigh Day.
In a statement following the conclusion, Laura-Jane’s family said:
“We urge all those involved in Laura-Jane’s care to reflect on the failures in her treatment and we hope that Mid and South Essex NHS Foundation Trust will take strong and swift action to ensure that these failures are never made again.
“We as a family have been extremely blessed to of had Laura-Jane in our lives, if only for a short time. She lit up the room when she walked in. Laura-Jane had the widest smile, the most infectious laugh and knew how to make everyone in the room feel important.
“Nothing gave her more joy however than being a mum, that’s all she ever wanted to be and that’s what she did best, she would be so proud of her children if she could see them now. A wonderful legacy although Laura-Jane’s gone, she lives on through her beautiful babies.
“We know that Laura-Jane would want anything learned from this inquest to be used to support and update medical knowledge, improve care to women in her position and most importantly to help others. Laura-Jane would not want anyone to experience what she went through and what we are as her family are living through day in and day out.”
